An Action Plan
For Healthy Bones

by Sandra Gordon

Katy Koontz was 38 and the mother of an active 4-year-old girl when her doctor delivered some upsetting news. The Knoxville, Tennessee, mom—whose period inexplicably never came back after the birth of her daughter—was in early menopause. Concerned about the rapid bone loss that occurs when a woman’s period stops, her doctor referred Koontz for a bone-density test. “I thought it was weird that I was in menopause, but I didn’t expect anything unusual because I had always been healthy,” says Koontz, who regularly walked five miles per day. When she learned a few days later that she had severe osteoporosis—bones so brittle that they could easily fracture—she was horrified. “My doctor said she had last seen bones like mine in an 83-year-old,” recalls Koontz, now 46. Overnight Koontz’s life changed dramatically. A lifelong skier, she had to give up the sport for fear of having a bone-shattering fall. Ditto for ice-skating and sledding with her daughter, Sam. “I suddenly felt old and fragile,” says Koontz.

What happened to Koontz is shocking because she’s so young, but she’s hardly unique. An estimated 15 million American women in their 40s or younger have osteoporosis, making them vulnerable to potentially devastating fractures of the hip, spine and wrist. Women tend to have bones that are smaller and less dense than men’s and lose bone more quickly, explaining why 80% of the nation’s 10 million osteoporosis sufferers are women. An additional 34 million American women have a serious but less debilitating condition called osteopenia: bone mass that’s significantly lower than normal, putting them at high risk for osteoporosis.

It’s never too late to start improving your bones. The steps you take now can pay off for a lifetime.

Why Your Bones Change—and When

Though we think of bones as being static and unchanging, they aren’t. They are composed of living tissue that is constantly in flux. Two types of cells that help with bone formation are osteoblasts, which make new bone tissue, and osteoclasts, which break down current bone tissue in a process known as remodeling. To build and maintain bone, your body needs a steady supply of calcium (along with Vitamin D to maximize calcium absorption) and estrogen. Bones also need weight-bearing exercise, such as walking, strength training or jogging. But exercise alone won’t keep bones healthy, as Koontz learned.

While we’re young, this process ticks along smoothly, with the body building bone more rapidly than it loses it, till we reach our peak bone mass in our mid-20s. Then the scenario changes and we gradually lose bone faster than it can be replaced. When estrogen levels fluctuate during perimenopause (it typically starts between age 45 and 47) then plummet after menopause (about 51), bone loss accelerates.

That’s why we need to be vigilant about keeping the bone we have. Indeed, the only way to prevent osteoporosis is to make bones as strong on possible when we’re young and keep them healthy as we get older, says Bess Dawson-Hughes, M.D., Director of the Bone Metabolism Laboratory at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, in Medford, Massachusetts. Think of eating well and exercising as making deposits in your bone bank. Surveys show that nine out of ten women don’t get enough calcium to help maintain bone health. And only 40% of Americans exercise regularly.

If you’ve been remiss, you can still start helping yourself now. Case in point: Katy Koontz began taking a prescription bone-building medication as well as a calcium supplement to slow down her bone loss and strengthen the bone she had while continuing to walk five miles daily. Each year, her bone density improved slightly. Nearly a decade later, though she still has osteopenia, her doctor is so pleased with her results that Koontz has returned to the slopes.

Your age and your estrogen level determine which strategies make the most sense for you. Here’s what you need to know to baby and bolster your bones at each stage of your life.

ages 19-24

What Happens: During these years, you reach your lifetime peak bone mass. Childhood sets the stage—you build about 60% of your skeleton then—but the rest comes during adolescence and your 20s. That’s when high levels of estrogen and two other hormones, growth hormone and insulin-like growth factor-1, increase bone density, helping you develop about 40% more bone than you had in your teens. You’ll need it: “A peak bone density that’s just 5% less than what it might have been can lead to a 40% increase in your risk of osteoporosis,” says calcium researcher Dorothy Teegarden, Ph.D., a professor of nutrition at Purdue University, in West Lafayette, Indiana.

Your Healthy Bone Regimen: Consume 1000 milligrams (mg) of calcium per day—slightly more than three 8-ounce glasses of skim milk—and 200 International Units (IUs) of Vitamin D. (Milk is an excellent source of D, as well.) If you don’t get enough calcium from your regular diet, take a daily calcium/vitamin D supplement or a multivitamin containing these ingredients to make up for the shortfall. To maximize bone growth you also need to do weight-bearing exercise that challenges your body’s large muscle groups (shoulder muscles, back and pelvic area). Good choices: strength training, running, walking or step aerobics.

Special Bone Strategies

Inventory your habits. Coffee, cola and other caffeinated drinks inhibit calcium absorption slightly—for every eight ounces of coffee you consume, your body fails to absorb 4 mg of calcium. That’s a trivial amount when you’re supposed to be consuming 1,000 milligrams a day. The main reason to monitor caffeine is that, if you sip a lot of black coffee or soda, you’re less likely to drink milk. To spare your bones, limit caffeine to two to three 8-ounce servings a day, advises Nelson Watts, M.D., Director of the Bone Health and Osteoporosis Center at the University of Cincinnati College of Medicine. Sneak in an extra 40 mg of calcium a day by adding two tablespoons of milk to your coffee or tea, or indulging in cappuccino, latte or milky chai (low-fat or fat-free milk will give you even more calcium per serving). If you smoke, your bones are yet another reason to quit—the habit can weaken them. So can too much alcohol, so limit it to six ounces of wine, twelve ounces of beer or one ounce of spirits per day.

Watch the salt. Sodium makes your body excrete more calcium than usual when you sweat or urinate. We need only about one teaspoon of salt per day; most of us get far more, primarily from packaged foods. Eat more fresh foods; switch to lower-sodium versions of packaged products.

See your doctor if your period stops. If you miss your period for three consecutive months or more—and you’re not pregnant or nursing—get to a doctor. Amenorrhea can occur for many reasons, including an eating disorder or excessive physical activity. (Ballet dancers and athletes, for instance, may miss periods due to low body fat.) Whatever the cause of the problem, the consequences are the same: estrogen levels drop, preventing bone-building cells from doing their job, a loss that can’t be recouped later, says Michelle P. Warren, M.D., Director of the Center for Menopause, Hormonal Disorders and Women’s Health at Columbia University Medical Center, in New York City.

Be scrupulous about calcium if you take birth control pills. The pill maintains a steady level of estrogen, preventing the surges of estrogen that can aid bone formation. To protect bone, make sure you meet your calcium quota. Dr. Teegarden recently found that young women on the pill who consumed 1,000 mg of calcium per day didn’t lose bone in their hip or spine over the course of a year. By contrast women on the pill who got 800 mg or less lost up to 2% of their bone mass in these areas.

ages 25-39

What happens: Your peak bone-building years have ended and you’re beginning to gradually lose bone more rapidly than it is replaced. Though you can’t stop the natural process, getting enough calcium, vitamin D and exercise can help slow it down.

Your Healthy Bone Regimen: Keep up the calcium and vitamin D. Your needs are the same as in young adulthood: 1,000 mg of calcium and 200 IUs of vitamin D per day, from diet alone or by adding a supplement.

Strong Bone Strategies

Make exercise a routine. If you have kids or a demanding job, you may find yourself slacking off on exercise. Don’t. Try to walk at least 7,500 steps a day—about three miles. “Women in their 20s and early 30s who walk a mile or more each day reduce their risk of hip fracture by 30% as they grow older,” says Miriam E. Nelson, Ph.D., Director of the John Hancock Center for Physical Activity at Tufts University and coauthor of Strong Women, Strong Bones. If you can manage to squeeze in some strength-training, even better. If you can’t get to a gym, use your body weight to do push-ups, lunges, squats, calf raises and triceps extensions. (Do 8-12 reps and two sets of each exercise.)

Make sure you get your full quota of calcium and vitamin D when you’re pregnant or nursing. Though your calcium needs increase if you get pregnant or nurse your baby, your body compensates by upping the amount of calcium it absorbs from food; as long as you get 1000 mg of calcium a day, you’ll be fine. You’ll lose some bone when nursing, but regain it once you stop.

Tell your doctor about any broken bones. “Whenever you fracture a bone as an adult, you should investigate the possibility of osteoporosis with your physician,” says Kerry Siminoski, M.D., professor of radiology, diagnostic imaging and internal medicine at the University of Alberta, in Edmonton. This is particularly true for any low-trauma fracture—one that’s caused by a fall from standing or sitting height. Dr. Siminoski has found that women who broke a hip, back, wrist or ankle bone after age 20 were up to 10 times more likely to be at risk for osteoporosis.

ages 40-49

What happens: During perimenopause, the transitional years leading to menopause when estrogen fluctuates and your periods become irregular, you can lose bone at a rate of half a percent to three percent per year.

Your Healthy Bone Regimen: It’s too soon to up your calcium intake beyond 1000 mg/day (plus 200 IUs of Vitamin D), but be very sure you get this much, or your bone loss could be even greater. If you don’t get enough calcium and D from food, start taking a supplement. (If you enter menopause in this decade, read the next section.)

Strong Bone Strategies

Focus on strength training. It’s still important to walk or run, but now the force you exert on bone really has to be greater than what it’s used to in daily life, which is where strength training comes in. Ideally, join a gym: Resistance machines let you lift more weight than you can lift at home, advises Dr. Nelson. Studies show that 45 minutes of strength-training twice a week are all it takes to maintain bone mass and slow bone loss. If you can’t afford a gym, consult with a personal trainer who can design an effective at-home strengthening program.

Consider taking an oral contraceptive. Although the pill can be bad for bone in younger women, some studies show it can increase bone density in women who are beginning to lose their body’s natural supply of estrogen. If your period is irregular, the pill can regulate it—and stop hot flashes, which can start now. If you smoke or have high blood pressure, the pill is off-limits.

ages 50 plus

What happens: After your period stops, you can lose up to 30-50% of your bone mass over the next 10 years, says Felicia Cosman, M.D., Clinical Director of the National Osteoporosis Foundation, in Washington, D.C., and author of What Your Doctor May Not Tell You About Osteoporosis. Cut bone loss all you can in your crucial 50s and 60s.

Your Healthy Bone Regimen: Try to bump up your calcium intake to 1,200 mg per day and be sure to get enough vitamin D. Current guidelines call for 400 IUs of D from age 51-70, then 600 IUs thereafter. More than 70% of women ages 51-70 and nearly 90% of older women don’t get sufficient calcium orD. And get enough magnesium, too (women over 30 need 320 mg/day). Recent research suggests that every 100 mg of magnesium people age 70 and older consume translates into a one percent increase in bone density. For some, bone-building drugs can also help.

Strong Bone Strategies

Discuss osteoporosis with your doctor. How soon should you have your bones tested? If you have a family history or other risk factors, you may be a candidate for what insurers consider an ‘early’ bone mineral density (BMD) test. DXA, the best type, is essentially a low-dose radiation X-ray of your skeleton to assess the amount of calcium in your bones and gauge their health. Though BMD testing isn’t used as a screening tool for all women until age 65, most insurers will cover a baseline screening at menopause or sooner if you’re at risk for osteoporosis. It may make sense to insist on a DXA soon after 50, even if you’re not in the high-risk group, and pay for it yourself (about $200). “I believe we really should be testing all women at menopause at the latest because you can have no risk factors yet still have osteoporosis or very low bone mass,” says Dr. Cosman.

Calcium supplements: Probably a ‘must’ for most. The higher amount of calcium you need now may be difficult to get from food alone. Getting the amount right can make a difference—especially if you pair it with exercise. A four-year study at the University of Arizona, in Tucson, found that postmenopausal women who did a weight-bearing and strength-training program three times a week for 60-75 minutes and took an 800-milligram calcium supplement on top of their usual dietary calcium intake improved their bone mineral density by 1-2%. (Another reason to emphasize strength training now: Strong muscles help balance, which reduces your risk of falls and fractures.)

Boost your B vitamins. Now, more than ever, you need folic acid and vitamins B12 and B6 to lower homocysteine, an amino acid in the blood. Though an elevated homocysteine level is best known as a sign of heart-attack risk, reducing this amino acid also protects your bones. People whose levels are greater than 10-12 micrograms per liter are at high risk for hip fracture, reports Katherine Tucker, Ph.D., an epidemiologist at Tufts University’s Human Nutrition Research Center on Aging, in Boston. Sources of homocysteine-lowering B vitamins include green vegetables, such as broccoli and kale, and B-fortified cereal. If your levels are too high, you may need to take a prescription-strength vitamin B-complex supplement.

Ask your doctor about bone-saving medications. On the basis of your bone density, medical history and other risk factors, you may be a candidate. But even if you take one of these drugs, you should do weight-bearing exercises to improve your strength and balance and make sure you get enough calcium and vitamin D. •

from the September-October 2006 issue

Think of eating well and exercising as making deposits in your bone bank.
More than 70% of women ages 51-70 and nearly 90% of older women don't get sufficient calcium.